Sharing and Using data for better health and care across Thames Valley and Surrey

Dr. Claire Fuller,

Senior Responsible Officer

Surrey Heartlands Integrated Care System (ICS)

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What is the Thames Valley and Surrey Local Health Care Records Partnership?

1 We are a coalition of health and care organisations, working together with our local communities to improve their health and wellbeing.

2 We serve a total population of 3.8m and include:

• 6 health and care systems (of which 5 are Integrated Care Systems)

• 6 Global Digital Exemplars

• 3 Sustainability and Transformation Partnerships

The Surrey Heartlands Perspective …

3

Oxfordshire Health & Care System

Buckinghamshire ICS

Berkshire West ICS

Surrey Heartlands ICS

Milton Keynes

ICS

A mature partnership• With a unique Devolution agreement• One of just 14 Integrated Care Systems

across the country

1 Aiming to make a real generational change for local people• Focus on first 1000 days• Wider determinants of health• Real collaborative approach

2

With a unique approach to citizen and staff engagement

• Citizen-led engagement programme and toolkit

• Surrey Heartlands Academy and focus on professional leadership

3

Some of our challenges …

4

We are a new partnership, working together as a whole for the first time

• STPs and ICS don’t perfectly align• There is range of architecture in

place • 3x Graphnet, 1x Cerner

interoperability programmes

12 Each system is on its own

digital transformation journey

• Different digital maturity and vision / priorities

• Different legacy of technology enabled change

3 We are building a partnership, based on local ownership

• Developing a shared vision of LHCR opportunities

• Much to learn from each care system and from this LHCR community

• Learning by participating

ICS / STP Priority Themes

Tuesday, March 12, 2019 5

ICS / STP priority themes Digital enablement via the LHCR

Prevention, wellbeing and self-care

• Population analytics enabling identification and targeting of need. • Healthy lifestyle services supported by digital tools and apps integrated with the shared care record

platform and national Empower the Person services. • Person Held Record to help to manage long-term conditions and upload, where appropriate, self-

monitored data for review and follow-up.

Urgent Care re-design / integrated primary & community care

• Care professional access to the right information in any setting and site across the footprint.• Multi-disciplinary teams supported by shared information and care-coordination capabilities. • Analytics for advanced predictive capacity and demand modelling.

Frailty Management • Risk modelling and clinical decision support that interfaces directly to the care record. • Care-coordination across MDTs. • Supported discharge and interface between social care and health.

Acute collaboration and efficiency

• Shared access to information and work-flows across sites.• Joint intelligence and PHM capabilities enabling effective care pathway management.

Population Health Management

• Applying advanced PHM analysis to identify gaps-in-care and provide impactability modelling to inform care plans.

• Identification and management of population cohorts to support evidence-based care management.

Commissioning for value and outcomes

• Risk modelling, patient segmentation and the development of outcomes measures for new forms of integrated commissioning and contracting.

We want to harness the power of digital services and innovations …

… to enable individuals and support communities to manage their health and stay healthy

Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health

Institute

Contributors to Health Outcomes

smoking

diet/exercise

alcohol use

poor sexual health

education

employment

income

family/social support

community safety

access to care

quality of care

environmental quality

built environment

Health Behaviours

30%

Socioeconomic Factors

40%Clinical Care

20%

Environ-ment

10%

We have to concentrate action on all fronts

1 2 3 4

10%

10%

5%

5%

10%

10%

5%

5%

10%

10%

10%

5%

5%

And combine this with a focus on population health systems

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Source: The Kings Fund

Sharing information between acute, primary, community, mental health, and social care for the benefit of patient care

The principles of our programme …

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3EMPOWERING

CITIZENSSHARING RECORDS

1 2INTELLIGENCE

Mobilising data using advanced analytics to help focus resources and

improve patient outcomes

Engaging people in their own care and treatment -

improving outcomes, reducing unnecessary follow up

appointments, and reducing emergency admissions

1

2

3

A vital first step …

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A vital first step for us is the development of a Thames Valley and Surrey-wide “shared record platform” which will be the foundation for

using data to improve direct care and population health applying advanced analytics and intelligence. In technical and architecture terms it looks like this:

Supporting population health

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Linked data from each local hub will flow into a data repository covering our whole geography, allowing analysis and reporting

SHA

RED

R

ECO

RD

S

We will integrate and normalise data from existing local shared records …

POPULATION HEALTHPLATFORM

1 2 … link and anonymise (or pseudonymise) for analysis in a single regional population health platform

ANONYMISATION

PSEUDONYMISATION

3

Patterns of demand, patient flows and

outcomesPredictive modelling

/ risk stratification / impactability

modelling

Analytics and modelling required for

collaborative service planning for Thames

Valley & Surrey

• The platform will support predictive modelling. Techniques such as automated machine learning can derive extra value.

• Transfer of the analytical outputs back into the local hubs will be possible to support direct patient care.

• We will work with our AHSN ensuring data is presented in a way that is useful, while maintaining the privacy and opt-out preferences of our population.

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5

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A single place to go to for patient information

Oxfordshire Health & Care System

Buckinghamshire ICS

Berkshire West ICS

Surrey Heartlands ICS

BUCKINGHAM-SHIRE CCG

EAST BERKSHIRE CCG

OXFORDSHIRE CCG

MILTON KEYNES CCG

NORTH WEST SURREY CCG

GUILDFORD WAVENEY CCG

SURREY DOWNS CCG

SURREY HEATH CCG

BERKSHIRE WEST CCG

OXFORD UH

CERNER

H

MILTON KEYNES UH

CERNER

H

ASHFORD &ST PETERS

DXC

H

ROYAL SURREY

ALLSCRIPTS

H

ROYALBERKSHIRE

CERNER

H

BUCKINGHAM-SHIRE

HEALTHCARE

SYSTEM C

H

FRIMLEY HEALTH

DXC

H

LIQUIDLOGIC

OXFORDSHIRECOUNTY COUNCIL

LA

LIQUIDLOGICCORELOGIC

BRACKNELLFOREST

BR COUNCILLA

LIQUIDLOGIC

SURREY COUNTYCOUNCIL

LA

CIVICA

R .BOROUGH WINDSOR

MAIDENHEADLA

CORELOGIC

WOKINGHAM DISTRICTCOUNCIL

LA

CAREWORKS

WESTBERKSHIRECOUNCIL

LA

LIQUIDLOGIC/CORELOGIC

MILTON KEYNES

COUNCILLA

CORELOGIC

READINGBOROUGHCOUNCIL

LA

LIQUIDLOGIC/NORTHGATE

BUCKS’COUNTYCOUNCIL

LA

LIQUIDLOGIC

SLOUGH BRCOUNCIL

LA

RIO

BERKSHIREHEALTHCARE

MHT

RIO

SURREY & BORDERS

CMHT

RIO

OXFORDHEALTH

CMHT

SOUTH CENTRAL

AMBULANCE SERVICE

49GP

H

H

H

H

H

H

HLA

CMHT

LA LA

LA

LA

LALA

CCG

CCG

CCG

CCG

CCG

CCG

CCG

CCG

CCG

LA

72GP

51GP

27GP

Milton Keynes ICS

Frimley Health ICS61GP

97GP

357GP

PRACTICES

3,800,000CITIZENS

Car

eCen

tric

National Services also integrate

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NATIONAL RECORD LOCATOR SERVICE

TERMINOLOGY SERVICE

EVENT MANAGEMENT

How it works …

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FORMS & WORKFLOW

Extr

act

Mes

sagi

ng

and

Inte

grat

ion

En

gin

e

… via a messaging extract engine

2

Car

eCen

tric

D

ata

Sto

re

CYBER SECURITY / AUDIT / IG

… to a cloud based clinical data store ..

3

BI ANALYTICS AND POPULATION

HEALTH

CCG/ ICSDirect,

De-ID ,and Research

Databases

5… with data also available for population health

Users from all care settings collect patient data on local systems … and this is sent …

1

PATIENTS & CITIZENS

NHS LOGIN

DIRECTORY OF SERVICES

PERSONAL HEALTH

RECORDS

… and patients can access and engage with their record

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WEARABLES

GP PRACTICE DATA

CHILD HEALTH DATA

SOCIAL CARE DATA

AMBULANCE SERVICES DATA

PATIENTS AND CITIZENS DATA

COMMUNITY DATA

ACUTE HOSPITALS DATA

EXTERNAL APPS

GP PRACTICES

OUT OF HOURS SERVICES

SOCIAL CARE

COMMUNITY & MENTAL HEALTH

AMBULANCE PARAMEDICS

ACUTE HOSPITALS

… for access from all care settings, by social care users, service providers and commissioners…

4

HIGHWAY IE

FHIR

OUT OF HOURS SERVICES DATA

OTHER SHARED CARE RECORDS DATA / CERNER

MENTAL HEALTH DATA

STAFF IDENTITY SERVICE

Rhapsody

Very rich data sets are collected and shared across the LHCR

MPI

CPA Details

Diagnoses

Clinical Notes

MH Act

Risks

MPI

Immunisations

Care Plans

Problems

Interventions

Diagnoses

Administration

Alcohol Exercise Diet

Allergies

Glucose / HbA1C

Blood Chemistry

Cervical Cytology

Blood Pressure

Child Health Data

Chronic Disease Data

Contraception & HRT

ECG Pulmonary

Family History

Heamatology

Height & Weight

Other Diagnostics

Medication Issues

Other Therapeutics

Pregnancies etc.

Smoking

Urinalysis

Immunisations

Active Problems

Encounters

Operations

Obstetric Procedures

Cytology

Other Pathology

Problems List

Social History

Physiology Tests

Investigation Admin

OTC Prophylactics

Referrals

Medication Admin

Admissions

Past Problems

Diabetes Diagnosis

Contraindications

Recent Tests

Active Problems

Encounters

Microbiology

Repeat Medications

Car

eCen

tric

SHA

RED

CA

RE

REC

OR

D

MPI

Waiting Lists

ADT

Referrals

Appointments

A&E Attendances

Theatre Visits

Orders / Results

Reports

Medications

Correspondence

Clinical Summary

Alerts

Contacts

Diagnoses

Procedures

Involved Professionals

MPI

Referrals

Events

Case Details Care Plans

Professionals

Services

Contacts

MPI

Clinical Summary

GP Practices

Cancer

Urgent Care

Mental Health

Summaries

Risks/Hazard/Alerts Disabilities

Protection Notices

Indicative data feeds might include …

Patient / Citizen

Survey data

About me

GP Practices

EIP Medications

All the information a clinician needs on a single screen

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A patient banner provides positive patient identification every time we access patient information

1

Scroll down for more details –like orders and results…

Information is clearly shared in tiles

2

3

… engaging patients in their own care

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Engaging Patients in their own Care

A subset of the full shared care record for patients to see, to include letters, past and future contacts, medications, allergies and problems.

The ability to share the record with family and carers and other professionals such as pharmacists

Correspondence and messaging eliminate the posting of paper letters across the patch and include the addition of future contacts to patients’ outlook calendars

A facility for the patient to review, cancel and hold outpatient appointments

Some benefits we might expect to see …

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Better Clinical Decisions

Cheshire has found that having access to a rich clinical history and recent health events helps clinicians in A&E to make better decisions

Door to Needle Time Reduced

Nottinghamshire reports that early access to the shared record plays a part in reducing the door to needle time for thrombolysis patients …

Supporting MDT Meetings

Users find that being able to look at patient data from all care settings on a single screen streamlines MDT meetings

Better End of Life Care

Manchester have added end of life care plans to the record –visible to all appropriate carers …

Early Warnings for Frailty Patients

By promoting frailty scores and information, carers can make better decisions about a patient’s care needs; for both medical and non-medical interventions.

Reduced Workload for Social Workers

Cheshire have found that Social Workers benefit too, saving time and seeing a reduced workload ..

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Next steps

Target operating model:

Focus on the operational running of the platform in partnership with the selected supplier, including service management of the data platform and the governance model

1

IG framework:

Working with national and local leads to develop the IG framework

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Benefits and enabling transformation:

Working with a wide range of networks and the Integrated Care Systems across Thames Valley and Surrey

Ethics and Social Acceptability Board:

Setting up a Board to provide independent advice and scrutiny of how we engage on the sharing and use of health and care data, and to advise on the methods and best practice of engagement and co-production with citizens.

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4

Thank You

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